Daughter: “Strawberries with whipped cream on the yellow plate for me. Lulu wants the purple plate…”

This is a daily interaction. My daughter is five, and she wants to be in control with significant personal autonomy. We want her to at least believe that to be the case, so choice architetecture is a skill that my wife and I have spent a lot of time to develop. If we don’t give her a choice, and just hand her strawberries with whipped cream, she’ll refuse the strawberries. If we give her fifteen choices, one of two things happen. If she is not exhausted, she asks for a more limited choice set. If she is exhausted, she meltdowns as the cognitive load of deciding what she wants for a snack is too much for her tired brain.

The key to our choice architecture is for mom and dad to curate the option space down to a reasonably narrow set of choices where none of the choices are bad. Last night, I had a mild preference for her to choose carrots and hummus as I would have enjoyed carrots and hummus leftovers from Lulu’s plate, but I was functionally indifferent to the three choices she had. She was able to make a good choice, feel like she was in control and be a BIG GIRL.

Adults tend not to go into incomprehensible crying fits when they encounter too many choices which overwhelm their cognitive processing ability. Instead, they choose quickly and they tend to choose poorly. Medicare Part D is an illustrative case via Incidental Economist:

Jason Abaluck and Jonathan Gruber [ungated working paper version here] observed that Part D enrollees had difficulty making their initial plan choices when Part D started in 2006. They found that beneficiaries paid more attention to plan premiums than to their own total out-of-pocket health expenses. Florian Heiss and colleagues, using 2007 and 2008 Medicare Part D data to study plan choices, found that fewer than 10 percent of consumers enrolled in the least costly plans in 2007 and 2008 and that beneficiaries could save on average about $300 per year if they switched plans. [Links added.]

For my age, income and family status, there were fifty two choices on the Exchange that I could buy. If I entered the zip code of my older sister’s favorite show from the early 90s, there were forty eight choices. If I used my parent’s zip code, twenty three choices appeared. If I used my first apartment’s address, sixty three choices appeared. If I made the prospective buyer 29 years old, another eight to twelve choices of catastrophic policies were added for all zip codes. If I dropped my income to qualify for cost-sharing assistance, another six to eight choices per address popped up.

If I had to buy insurance, I would be in choice overload and buy based on simple heuristics that are not even satisficing on anything other than stopping the process quickly much less optimizing for the best health plan that meets my anticipated healthcare needs given my financial constraints.

One of two things should happen for the 2015 open enrollment period on the federal exchange. The first is a structured decision support tool could be added. This tool would allow for the full array of choices to be made available to any shopper. However, it would ask several filtering questions. These could be a simple as: “do you want low premiums but high out of pocket expenses or higher premiums and lower out or expenses” and “do you already have doctors that you want to keep in network, or do you really not care who your doctor is”. A few more simple decision support questions would quickly narrow down the shopping scope to three or four choices. That is a managable cognitive load where satisficing choices have already been brought into the potential optimizing option space.

The other option is for the federal exchange to transition from a clearinghouse model where any minimally qualified plan is displayed and available for sale to an actively managed market model where the Feds either set strict definitions as to what can be sold, or choose a subset of plans to sell from the qualifying plans. I don’t think this will happen due to the need to have insurance company buy-in as the losing companies will have a legitimate reason to scream.

Oh my god. Thank you for this. This is such a huge fucking deal for me. I wrote about this back in 2009, “You Say Choice, I Hear Big Fucking Hassle.” This whole “shopping” narrative is so ingrained in the American psyche, like shopping is always a great thing. I fucking hate to shop. I do. The very last thing I want to do is “shop” for my healthcare. ALL I want to do is see the doctor of my choice without getting raped in the wallet in the process. That’s it. Is that so fucking hard?

I’ve been trying to explain this to one of the managers here at work — if you want people to make a decision about a project, you need to tell them what the choices are and limit the number of choices (again, usually the magic number of three) or you will never get a consensus.

Whenever we have an activity to vote on at work (potluck theme, etc.), I usually stick with three choices rather than just, say, having each of 20 people write in what they want. Cleaner for everyone.

Well, they have rating systems on Part D plans now that let you see how the plans are at things beyond price. Can’t really do that until there’s some history to the exchange, of course, but it might help.

@Mnemosyne: with my daughter, I find 2 to 4 serious choices are ideal, although throwing in a nonsensical choice will just makes her laugh — so snack options are peaches, strawberries with whipped cream, hummus and carrots, apples or worms. Anything more than that, she hits her processing limits.

This is the same reason I cannot shop for clothes at TJ Maxx. There are too many pieces of clothing too close together and my eyes glaze over.

When I have to do something stressful like figure out like insurance, my eyes glaze over and, even worse, I am like the paralyzed bunny in the headlights. I cannot make any choice at all. Just make it stop!

Gee, if only there was some mechanism in place, you know, like people trained to assist newbies in steering through this sometimes confusing process. Sort of a navigator or something. Like the person in the passenger seat when you’re driving around unfamiliar territory, who can help you watch for road signs. But what would you call it? That’s a stumper for sure.

The good news is that with annual open enrollment periods, if you make a poor choice that first year, you can make a better informed choice the next year, perhaps even in consultation with your doctor or clinic.

Of course, if Congress had spent a little more time improving the Affordable Care Act over the last four years, and less time trying to “repeal” “Obamacare,” some of these problems might have been effectively addressed in a timely manner.

This is where I think the sandboxed choices of Most Civilised Countries That Do Healthcare Properly make sense: the kinds where you can choose whether you want to pay the extra for the private room with fresh flowers every day and all the cable channels.

Even when it affects actual care delivery — say, in Australia — then it’s usually along the lines of “good, better or best”.

The US model right now makes you feel like you’re picking your poison, and that the insurance companies will screw you one way if you choose not to be screwed another, but there’s no “I will pay an appropriate amount and not be screwed” option. It’s like buying cable service.

Sounds like my niece. Her parents want her to feel “in charge.” They didn’t like what happened. At two she refused to eat any meat. She had that toy I think all kids have, where you pull a string and it says “and a cow goes moo.” When offered food she would ask if it went moo.

She now eats almost no meat. Will only drink soy milk. At first her parents though her liberal uncle (that would be me) told her to do this. I was like (1) I eat meat and (2) I would never attempt to “father” your daughter.

Although I like they let me makes choices, there is a part of me that wonders if this is really the best thing. I mean her parents are older, smarter, and have more life experiences. Maybe it isn’t a bad thing for a parent to tell a child what to do.

My spousal unit and I go through this every freaking October during the open enrollment period. For some reason the plan we chose the year before is ALWAYS discontinued for the next year, I imagine because the insurance co. was not making enough profits from it. My wife, who is in the insurance industry, sits down with the print out of the dozen or more insurance options, then my eyes glaze over while she tries to explain the distinctions without a difference between the plans. Eventually we just guess on one and hope it all works out.

Somehow I think that each of the plans all end up at the same place more or less for the insurance company, but for the consumer it’s just a matter of whether we want to pay now or pay later. I hate, hate, hate the whole concept of health insurance. My wife, who has been in the industry for thirty years, can not comprehend how the average American can possibly make an informed rational decision from the pile of manure that gets shoveled at them in a language they don’t really understand. It’s as if the insurance companies have all collaborated to make it as difficult for consumers as possible.

@Tommy: The difference is the structured versus unstructured nature of choices.

In my example above, I’m giving her choices that are objectively good for her. I really don’t care if she chooses A or B or C, and those are the three choices she is making. Choice K or Choice R is not in the option space. for instance, last night we went out to go grocery shopping. We gave her a choice to wear her sparkly hat or her owl hat. She was going to wear a hat no matter what, but it did not matter which one she wore. An open ended command to put her hat on meant she would think about the four hats she owns, plus my hat, plus my wife’s three cool hats, plus a scarf as the option space. Telling her to put on her sparkly hat gets passive-aggressive resistance. Her choosing the sparkly hat got her out the door in fifteen seconds. Her mom and I are driving the process, we are giving her the illusion of control.

The hope that we have is two-fold. First, it gets her buy-in as to baseline good habits so in future years she thinks a snack is a piece of fruit or hummus and a carrier instead of a pack of cookies. We’re trying to internalize good habits before she realizes that is what we’re doing. Secondly, it is developmentally appropriate for a kid her age to assert her independence. The question is how does she assert her independence. Is it social or anti-social?

I like to think I am pretty smart. That I know more about health care then most folks. When I went to the exchange to buy my program I was overwhelmed beyond words, and I had fewer choice then you did Richard. There were too MANY choices. The differences between some programs, I couldn’t even really tell what they were. I spent maybe 20+ hours reading the benefits of each plan. Doing some research.

Honestly, I might have been more confused after I did this then before I started.

I agree with what you said, there needs to be a better automated comparison tool. Or even a tool that gives me a survey about my medical needs, history, and background that suggests some programs based on my needs/requirements.

Just a side story. I am nothing close to a world class programmer. But I created, with COTS (commercial off the shelf) software, an advance shipping program for a large client of mine. They are a shipping company of record for a large chain store that sells flooring and kitchen and bathroom stuff. The shipping options are close to limitless and we gave them an easy way to compare their options. It took me about 100 hours. I’d say 20% of that was just learning a new app, not setting up the program itself.

Clearly health care is more complex, but don’t tell me for a second this can’t be done in a more effective and elegant manner.

But but but the Republicans tell me that lots and lots of choices will make me happier plus it also serves as a useful sorting tool to help make sure less intelligent people or people with less time are likely to make poor choices and then I can blame those people for making poor choices.

@Richard Mayhew: No I totally understand what you are doing. You know the outcome you want, she will wear a hat cause it is cold outside. But as you said you don’t demand she put on a hat, you ask her which hat she wants to wear.

My gut is my brother and his wife took this too far. Maybe a little off topic here ….. but …..

My brother and I were raised in an amazing household, but to be honest our lives were controlled in every way possible (kind of the military family thing). It took us years and years from when we left the household (and we ran away to be honest) to get out of the mindset there was ways to do things that were different then how we were raised.

In fact for about 15 years I almost never talked to my parents. I then came to realize my parents loved me in ways that are hard to put to words, but maybe not in a way I wanted. And that to be honest, this was how they were raised. So they did it to us. Control everything. Choices are not an option. You do it our way, cause well it is the way things should be done.

My brother, and we’ve not really talked about this much, is trying to change that. Another difference is Katie is the first women born in my side of the family since 1918. A lot of only male children. Well single male children most of the time.

My brother’s wife is a few years older then him, well more then a few years older and she was raised in a military family as well. Women were supposed to be “seen and not heard.” Sarah (my brother’s wife) was never like that. A strong, smart women. I think factored into my brother’s background and hers, they are offering up choice that maybe don’t need to be offered.

I have a degree in psychology and your I want my daughter to relate snacks to fruit or humus is key. That you give her a choice, no matter what she chooses you are cool with, is something I will bring up to my brother. I have to admit I never really thought of something like that, well that way. But both simple and an elegant concept at the same time.

The name for this in the psychology literature is “the paradox of choice”. There’s a great (very readable) book by that name by Barry Schwartz that explains it. The original finding is that if you give people too many choices they avoid the decision entirely – even if it’s for something important that they really need to be buying like a pension plan.

With kids I call it the fine art of the false dichotomy. As Richard points out, it’s all about manipulating the problem space to allow them to operate within their abilities as intrinsically motivated agents with control over their surroundings… plus it gets them doing the things you need them to do. At some point they can get wise to the game and start demanding changes to their options (“I don’t want any of those”), but I think even that can be reduced if the choices they are given are set up well enough.

ETA, wish there was some way I could “rec” or otherwise boost this awesome post :)

@Ecks: yep — the jelly experiment — get people in a supermarket with the command to buy jelly. If there are 3 brands of jelly, this is an easy task. If there are 36 brands of jelly, people can’t make a choice.

I’ve got a six year old son, so yeah: two or three choices is good, four okay. Five is right out*.

And a few months ago, my wife and I selected a dental plan to go with our federal BC-BS health coverage. There were six or seven choices, and it was a pain in the neck to choose among even that many in a rational manner, rather than throwing a dart at a page with their names all printed out.

Since I’m sure I’ve got more ability to decipher this crap, and more patience for it, than 95% of Americans, we really do need some way to cut WAY down on the number of options most people have to sort through. Three or four choices is okay. Dozens are simply right out.

@Richard Mayhew: Oh, Richard.I’m so glad this works for you now, with this daughter. But don’t be surprised if your emergency back-up child (or this daughter at an older age) responds, “I don’t want to wear any hat. Or gloves.” Or some variant. Offering choices to my older son never worked. He always wanted a different choice, or no choice. I was flabbergasted when I discovered that it sometimes worked with my younger son.

We gave her a choice to wear her sparkly hat or her owl hat. She was going to wear a hat no matter what, but it did not matter which one she wore.

I once read an article about a grocery-store chain in France that offers only one kind of everything: diced tomatoes, toilet paper, pickles, whatever. You go in, grab what you came for, pay for it, and walk out. This seems extreme, but not long ago I was standing in front about fifteen different kinds of Crest toothpaste, and even though I kept telling myself “It doesn’t matter, just PICK ONE!”, I was frozen by indecision. I remember wishing I were in that store in France so I could just buy a tube of toothpaste and get on with my life.

Just wondering if anyone else has gone thru this. Hubby had a procedure done where they took some cells out to test for cancer.
First time they did it decided did not have right cells or something so they did it a second time. This was all done on same day, he just had to wait while they tested the first batch.

So looks like the hospital billed insurance for both times and I wonder if I should dispute the claim as they messed up the first time…or is this normal??

@Ecks: The problem is that we are wired to optimize the outcome. If you get the 2nd best price on something, you’re pissed because you missed the best price. It doesn’t matter if there were only 2 prices or 2,000, whether you missed by 50% or by .1% – everyone wants to optimize that decision, and with many options, it becomes impossible. So in response a lot of people throw up some arbitrary constraint to artificially limit their choices. They become Apple loyalists because Apple only gives you 2 choices to begin with, rather than dozens or hundreds (it would fair to say this applies to me). Or they become Ford loyalists because the hierarchy of options are clearly structured and easy to parse. Comparing similarly priced and specced Chevy and Ford is hard, but walking the ladder of Ford trucks (or Chevy) is much easier.

Costco plays this very well. There is virtually no choice there. If you want peanut butter, you can usually pick the single (usually quite good) brand they have on the shelf at a good price. You either pick peanut butter or you don’t. No dithering between brands or needing to compare labels or cost per ounce or whatever is part of your optimization strategy. If you want a vacuum, you can pick among the 1 or maybe 2 very distinct Dyson’s on the shelf. They usually break that strategy in places where people enjoy their choice or where loyalties come into play, such as with buying wine, or with soda (few people alternate between Coke and Pepsi) but most people aren’t loyal to their brand of green beans. Costco is where you buy, rather than shop.

@elftx: That’s pretty normal in my experience. The problem is often that the test for this stuff isn’t always conclusive, so they run it again. That’s based on our experience with the HMO, where there’s no financial motive to repeat bill.

Choices, choices. I ran into this when I applied for Medicare Part D – so many choices. However, this is the classic of pay the premium, even though you don’t take any meds. So every year, I pay $15 a month for stuff I don’t get or use. Why oh why, can’t supplements be on there? I found out that there is a penalty on Medicare Part D if you don’t purchase it when you turn Medicare age, and it increases each year, noting those costs could go up for a senior in that very fixed income. I frankly don’t hear the libertarian/republican crowd of seniors whining about that like their children whine about the ACA penalty.

@🎂 Martin: Got to disagree. People are not optimizers. They are satisficers. They’ll take good enough most of the time. I know when I want a steak, I am not sampling the fourteen steakhouses every time. I’ll go back to the restaurant that I know served a really nice steak last time I had that hankering and get a damn good steak. I don’t know if it is objectively the best steak I can get within a 30 minute travel radius from my house, and I really don’t care. It met my objective of eating a really good steak.

To be a bit cynical, we are satisficers on long term romantic partners as well. There may have been times in my life that I attempted and failed misterably in sampling the company of every available woman on my college campus and the surrounding community, but I never attempted to search the entire world. And when I met my wife, I stopped searching despite the possibility that a better match was out there three time zones away.

@Richard Mayhew: sure, but how can I decide that I’m better off with a 6 month contract vs a 24 month contract to try and winnow choices, given that 24 month contracts are more expensive (plus the fact that they all charge some fee if I use less than 1000 kWh a month). If I choose the cheaper short term option now, I get to do this all over again in a couple months. Furthermore, online reviews all point out that about 3/4 of the distributors are crappy, so while reducing the option set to 4 is easy, knowing which options to pick to reduce it to a worthwhile 4 is still near impossible.

Oh, so that’s what it’s called.
30+ years ago, mrs efgoldman just explained it as an easy antidote to the terrible twos, when the kid learns “no” as the first real power word.
“Bedtime.” “No.” Fight ensues.
“Would you like your red jammies or your blue ones.” “The red ones.” Bedtime ensues.

Too many overlapping and hard to differentiate health insurance choices is nothing new. 30-40 yrs ago I purchased group health insurance for my company. Trying to make sense of the choices wasn’t really that difficult but it was very time consuming. Far more consuming than I had time for. What I had to do was learn to direct my insurance broker to look a all the plans and pick out 5 or 6 that would work for me. So same as what Richard is doing for his daughter. Take away the 20-30 choices available and show me the 5-6 that make some sense. Some years I would reject all 5 or 6 choices and give my broker the reasons why. That allowed him to understand my needs better and try again.

@Aurona:
That’s because being hypocrites they complain about it but they get Part D because it saves them money and Medicare is for all intents and purposes telling them they have to. They have daddy issues. And it was Bush who screwed up Part D. Let them know that President Obama has made it better and hear them scream.
My problem is that I reach Medicare age soon and have the VA. What do I do if I don’t take Medicare at all and the rethugs screw up the VA? Will I have to pay a huge penalty even though I have/had healthcare? No one seems to be able to answer the question and knowing my luck I’m sure to make the wrong one.

Enough it enough, and when Mayhew trots out the tired old scam of “choice,” we know we’re in Milton Friedman territory — the Big Con of “Free to Choose.”

Yes, you too have a choice! All the choice in the world! You can choose to go on medicaid…oh, wait, most states are slashing their medicaid funding because it’s bankrupting them. So you don’t really have that choice.

Or you have the choice to buy the unaffordable private for-profit health insurance of your choice through the ACA! But of course an increasingly number of people are getting fired or having their hours cut to the point where they can’t actually afford to buy unaffordable private health insurance. So that’s not really a choice either.

But you still have choice! If you're really really sick, you can go to the Emergency Room! What a universe of choices!

Let's take a look at Richard Mayhew's con game of endless health care "choices" by way of a concrete example:

It would be hard to overstate how badly public policy has gone wrong in the arena of American health care, but here’s a remarkable personal experience to suggest the outlines of the problem. In November, too sick on a Saturday night to wait for Monday, I went to the dreadful emergency room in my own neighborhood. It was my first—and last—visit to the place, and almost nothing at all happened: a nurse practitioner asked some questions, ordered some tests that he told me, as he sent me home, he hadn’t gotten around to reviewing, and suggested that I try to see a doctor on Monday. No diagnosis, no treatment, no doctor.

A month later came the punch line: an EOB to let me know how much of the emergency room physician’s $540 bill my insurance company had paid. The doctor on duty that night in the ER, having never seen me or spoken to me, billed me for her services.

After a fruitless exchange of letters, I called the California Medical Board, traveled around the phone tree, and spoke to a regulator. She explained the rules for billing by a doctor for services provided by a nurse practitioner. The doctor sending a bill has to “supervise” the NP, but doesn’t have to be physically present to do it—not even in the same building—and only needs to review “some percentage” of the NP’s patient charts.

This is a scam, “supervision” without supervision. To be sure, it does cut costs—it cuts the cost for the provider of medical treatment, but without cutting the costs insurers and patients pay for service. It’s a profit-enhancer, not a delivery system for cheaper medicine. A nurse practitioner treats patients, and a doctor who may or may not be in the building sends a bill. State law and regulation cheerfully embraces the practice, and doctors get paid without the unnecessary hassle of actually seeing patients or providing them with medical care.

And we wonder why our health care costs are the highest in the world. Anyway, let’s make everyone pay for this remarkable system, or use the Internal Revenue Service to punish people who opt out. What a great idea.

In between presiding over these kinds of grotesque scams designed to bilk sick people of their life savings and writing astoundingly dishonest screeds on this forum designed to defend the indefensible ripoffs and con jobs perpetrated by America’s medical-theft complex, we’d all like to know how much Richard Mayhew gets paid.

Tell us, Richard. How much money do you bring home every year for conspiring to perpetrate these kinds of con jobs, where sick people get billed $540 without ever actually seeing a doctor?

Do you take more more than $400,000 per year, Richard?

Is that why you constantly give us these cheery horseshit depictions of a broken U.S. health care system that qualifies as blunt and brutal fraud of the most crass kind?

Because, you know, Richard, it’s starting to sound like you’re another fucking Tom Friedman. You’re sitting there floating on a gusher of money, a goddamn Yellowstone Old Faithful geyser of hundred-dollar bills spewing into your bank account every month as CEO of Richard Mayhew Insurance, and we’d all really like to know just exactly what the fuck you’re doing to justify that kind of stratospheric income…other than stealing from sick people by running the kind of health-care scam described above.